Agent/Broker Eligibility and Consent Documentation

Supporting Statement for Agent/Broker Consent Information Collection (CMS-10840)

Documents and Forms

Document Name Document Type
Form CMS-10840 Agent/Broker Eligibility and Consent Documentation Form
CMS-10840 CMS Model Consent Form for Marketplace Agents and Broker CMS-10840_Agent-Broker_Consent_Appenidx_A_Consent_Form.pdf Form
CMS-10840 CMS Model Consent Form for Marketplace Agents and Broker CMS-10840_Agent-Broker_Consent_Appenidx_A_Consent_Form.pdf Form

Information Collection (IC) Details

IC Title:	Agent/Broker Eligibility and Consent Documentation	Agency IC Tracking Number:	CCIIO - 10840

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.220

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10840	CMS Model Consent Form for Marketplace Agents and Brokers	CMS-10840_Agent-Broker_Consent_Appenidx_A_Consent_Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,947,909	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	4,947,909	4,947,909
Annual IC Time Burden (Hours)	841,145	841,145
Annual IC Cost Burden (Dollars)	26,372,355	26,372,355

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.